Hernia Materials: Fundamentals of Prosthetic Characteristics

  • Corey R. DeekenEmail author
  • Spencer P. Lake


Hernia repair materials have advanced over the past 80 years to include over 150 designs at present. The Deeken & Lake Mesh Classification System was created to unify the terminology used to describe these biomaterials and provide insight into the nuances of the various designs. Meshes are classified in a hierarchical fashion, grouped first by the composition of the structural mesh component, and second by the presence of a barrier, coating, or reinforcing material. In addition to composition, surgeons must also understand the physical and mechanical properties associated with these materials in order to inform mesh selection. A series of prior publications are summarized which report the physical and mechanical properties of over 50 biomaterials commonly utilized for hernia repair. Many of these biomaterials meet or exceed the threshold values previously recommended by our group: suture retention and tear resistance strength >20 N and ball burst strength >50 N/cm, with strain in the range of 10–30%; however, it remains unclear whether these characteristics match the properties of the human abdominal wall as the mechanics of abdominal tissues and hernia biomaterials are incompletely understood. It is unlikely that any single biomaterial design encompasses all of the ideal physical and mechanical characteristics required to fully match the properties of the human abdominal wall. A complete set of target guidelines including strength, compliance, anisotropy, nonlinearity, and hysteresis should be established through continued testing of human abdominal wall tissue specimens and through sophisticated and well-informed modeling efforts.


Abdominal wall Adhesions Anisotropy Biomaterials Hernia repair Mechanics Mesh 



Dr. Deeken is an employee of, and Dr. Lake is a consultant for, Covalent Bio, LLC (St. Louis, MO). The preparation of this work was supported by funding from Colorado Therapeutics LLC (Broomfield, CO), C. R. Bard, Inc./Davol (Warwick, RI), Johnson & Johnson Medical GmbH (Norderstedt, Germany), and TELA Bio (Malvern, PA).


  1. 1.
    Cole P. The filigree operation for inguinal hernia repair. Br J Surg. 1941;29:168–81.CrossRefGoogle Scholar
  2. 2.
    Koontz AR. Preliminary report on the use of tantalum mesh in the repair of ventral hernias. Ann Surg. 1948;127(5):1079–85.CrossRefGoogle Scholar
  3. 3.
    Usher FC, Ochsner J, Tuttle L Jr. Use of marlex mesh in the repair of incisional hernias. Am Surg. 1958;24(12):969–74.PubMedGoogle Scholar
  4. 4.
    Deeken CR, Lake SP. Mechanical properties of the abdominal wall and biomaterials utilized for hernia repair. J Mech Behav Biomed Mater. 2017;74:411–27. Scholar
  5. 5.
    Amid P. Classification of biomaterials and their related complications in abdominal wall hernia surgery. Hernia. 1997;1:15–21.CrossRefGoogle Scholar
  6. 6.
    Earle DB, Mark LA. Prosthetic material in inguinal hernia repair: how do I choose? Surg Clin North Am. 2008;88(1):179–201.CrossRefGoogle Scholar
  7. 7.
    Deeken CR, Abdo MS, Frisella MM, Matthews BD. Physicomechanical evaluation of absorbable and nonabsorbable barrier composite meshes for laparoscopic ventral hernia repair. Surg Endosc. 2011;25(5):1541–52. Scholar
  8. 8.
    Deeken CR, Abdo MS, Frisella MM, Matthews BD. Physicomechanical evaluation of polypropylene, polyester, and polytetrafluoroethylene meshes for inguinal hernia repair. J Am Coll Surg. 2011;212(1):68–79.CrossRefGoogle Scholar
  9. 9.
    Welty G, Klinge U, Klosterhalfen B, Kasperk R, Schumpelick V. Functional impairment and complaints following incisional hernia repair with different polypropylene meshes. Hernia. 2001;5(3):142–7.CrossRefGoogle Scholar
  10. 10.
    O’Dwyer PJ, Kingsnorth AN, Molloy RG, Small PK, Lammers B, Horeyseck G. Randomized clinical trial assessing impact of a lightweight or heavyweight mesh on chronic pain after inguinal hernia repair. Br J Surg. 2005;92(2):166–70.CrossRefGoogle Scholar
  11. 11.
    Post S, Weiss B, Willer M, Neufang T, Lorenz D. Randomized clinical trial of lightweight composite mesh for Lichtenstein inguinal hernia repair. Br J Surg. 2004;91(1):44–8.CrossRefGoogle Scholar
  12. 12.
    Klinge U, Klosterhalfen B, Birkenhauer V, Junge K, Conze J, Schumpelick V. Impact of polymer pore size on the interface scar formation in a rat model. J Surg Res. 2002;103(2):208–14.CrossRefGoogle Scholar
  13. 13.
    Lake SP, Ray S, Zihni AM, Thompson DM Jr, Gluckstein J, Deeken CR. Pore size and pore shape—but not mesh density—alter the mechanical strength of tissue ingrowth and host tissue response to synthetic mesh materials in a porcine model of ventral hernia repair. J Mech Behav Biomed Mater. 2014;42C:186–97. Scholar
  14. 14.
    Deeken CR, Thompson DM Jr, Castile RM, Lake SP. Biaxial analysis of synthetic scaffolds for hernia repair demonstrates variability in mechanical anisotropy, non-linearity and hysteresis. J Mech Behav Biomed Mater. 2014;38:6–16. Scholar
  15. 15.
    Melman L, Jenkins ED, Deeken CR, Brodt M, Brown SR, Brunt LM, et al. Evaluation of acute fixation strength for mechanical tacking devices and fibrin sealant versus polypropylene suture for laparoscopic ventral hernia repair. Surg Innov. 2010;17(4):285–90. Scholar
  16. 16.
    Junge K, Klinge U, Prescher A, Giboni P, Niewiera M, Schumpelick V. Elasticity of the anterior abdominal wall and impact for reparation of incisional hernias using mesh implants. Hernia. 2001;5(3):113–8.CrossRefGoogle Scholar
  17. 17.
    Annor AH, Tang ME, Pui CL, Ebersole GC, Frisella MM, Matthews BD, et al. Effect of enzymatic degradation on the mechanical properties of biological scaffold materials. Surg Endosc. 2012;26(10):2767–78. Scholar
  18. 18.
    Deeken CR, Matthews BD. Characterization of the mechanical strength, resorption properties, and histologic characteristics of a fully absorbable material (poly-4-hydroxybutyrate-PHASIX Mesh) in a porcine model of hernia repair. ISRN Surg. 2013;2013:238067. Scholar
  19. 19.
    Eliason BJ, Frisella MM, Matthews BD, Deeken CR. Effect of repetitive loading on the mechanical properties of synthetic hernia repair materials. J Am Coll Surg. 2011;213:430–5. S1072-7515(11)00402-9 [pii].CrossRefPubMedGoogle Scholar
  20. 20.
    Est S, Roen M, Chi T, Simien A, Castile RM, Thompson DM Jr, et al. Multi-directional mechanical analysis of synthetic scaffolds for hernia repair. J Mech Behav Biomed Mater. 2017;71:43–53. Scholar
  21. 21.
    Pui CL, Tang ME, Annor AH, Ebersole GC, Frisella MM, Matthews BD, et al. Effect of repetitive loading on the mechanical properties of biological scaffold materials. J Am Coll Surg. 2012;215(2):216–28. Scholar
  22. 22.
    Ebersole GC, Buettmann EG, MacEwan MR, Tang ME, Frisella MM, Matthews BD, et al. Development of novel electrospun absorbable polycaprolactone (PCL) scaffolds for hernia repair applications. Surg Endosc. 2012;26(10):2717–28. Scholar
  23. 23.
    Cordero A, Hernandez-Gascon B, Pascual G, Bellon JM, Calvo B, Pena E. Biaxial mechanical evaluation of absorbable and nonabsorbable synthetic surgical meshes used for hernia repair: physiological loads modify anisotropy response. Ann Biomed Eng. 2016;44(7):2181–8. Scholar
  24. 24.
    Ferzoco S. Long-term results with various hernia repair materials in non-human primates. Poster at Abdominal Wall Reconstruction Conference 2016.Google Scholar
  25. 25.
    Ferzoco S. Novel reinforced bioscaffolds in non-human primate abdominal wall repair model. Poster at Abdominal Wall Reconstruction Conference. 2016.Google Scholar
  26. 26.
    Ferzoco S. Biomechanical evaluation of reinforced bioscaffolds: a new approach to hernia repair. Poster at Abdominal Wall Reconstruction Conference. 2016.Google Scholar
  27. 27.
    Martin DP, Badhwar A, Shah DV, Rizk S, Eldridge SN, Gagne DH, et al. Characterization of poly-4-hydroxybutyrate mesh for hernia repair applications. J Surg Res. 2013;184(2):766–73. Scholar
  28. 28.
    Schug-Pass C, Lippert H, Kockerling F. Mesh fixation with fibrin glue (Tissucol/Tisseel(R)) in hernia repair dependent on the mesh structure—is there an optimum fibrin-mesh combination?—investigations on a biomechanical model. Langenbecks Arch Surg. 2010;395(5):569–74.CrossRefGoogle Scholar
  29. 29.
    Kalaba S, Gerhard E, Winder JS, Pauli EM, Haluck RS, Yang J. Design strategies and applications of biomaterials and devices for hernia repair. Bioactive Mater. 2016;1(1):2–17. Scholar
  30. 30.
    Hollinsky C, Sandberg S, Koch T, Seidler S. Biomechanical properties of lightweight versus heavyweight meshes for laparoscopic inguinal hernia repair and their impact on recurrence rates. Surg Endosc. 2008;22(12):2679–85.CrossRefGoogle Scholar
  31. 31.
    Cobb WS, Kercher KW, Heniford BT. The argument for lightweight polypropylene mesh in hernia repair. Surg Innov. 2005;12(1):63–9.CrossRefGoogle Scholar
  32. 32.
    Brown CN, Finch JG. Which mesh for hernia repair? Ann R Coll Surg Engl. 2010;92(4):272–8. Scholar
  33. 33.
    Conze J, Kingsnorth AN, Flament JB, Simmermacher R, Arlt G, Langer C, et al. Randomized clinical trial comparing lightweight composite mesh with polyester or polypropylene mesh for incisional hernia repair. Br J Surg. 2005;92(12):1488–93.CrossRefGoogle Scholar
  34. 34.
    Pascual G, Rodriguez M, Gomez-Gil V, Garcia-Honduvilla N, Bujan J, Bellon JM. Early tissue incorporation and collagen deposition in lightweight polypropylene meshes: bioassay in an experimental model of ventral hernia. Surgery. 2008;144(3):427–35.CrossRefGoogle Scholar
  35. 35.
    Langenbach MR, Sauerland S. Polypropylene versus polyester mesh for laparoscopic inguinal hernia repair: short-term results of a comparative study. Surg Sci. 2013;4(1):29–34.CrossRefGoogle Scholar
  36. 36.
    Hollinsky C, Kolbe T, Walter I, Joachim A, Sandberg S, Koch T, et al. Comparison of a new self-gripping mesh with other fixation methods for laparoscopic hernia repair in a rat model. J Am Coll Surg. 2009;208(6):1107–14. Scholar
  37. 37.
    Langenbach MR, Schmidt J, Ubrig B, Zirngibl H. Sixty-month follow-up after endoscopic inguinal hernia repair with three types of mesh: a prospective randomized trial. Surg Endosc. 2008;22(8):1790–7. Scholar
  38. 38.
    Orenstein SB, Saberski ER, Kreutzer DL, Novitsky YW. Comparative analysis of histopathologic effects of synthetic meshes based on material, weight, and pore size in mice. J Surg Res. 2012;176(2):423–9. Scholar
  39. 39.
    Doctor HG. Evaluation of various prosthetic materials and newer meshes for hernia repairs. J Minim Access Surg. 2006;2(3):110–6.CrossRefGoogle Scholar
  40. 40.
    Voskerician G, Gingras PH, Anderson JM. Macroporous condensed poly(tetrafluoroethylene). I. In vivo inflammatory response and healing characteristics. J Biomed Mater Res A. 2006;76(2):234–42.CrossRefGoogle Scholar
  41. 41.
    Voskerician G, Jin J, White MF, Williams CP, Rosen MJ. Effect of biomaterial design criteria on the performance of surgical meshes for abdominal hernia repair: a pre-clinical evaluation in a chronic rat model. J Mater Sci Mater Med. 2010;21(6):1989–95. Scholar
  42. 42.
    Langer C, Neufang T, Kley C, Liersch T, Becker H. Central mesh recurrence after incisional hernia repair with Marlex—are the meshes strong enough? Hernia. 2001;5(3):164–7.CrossRefGoogle Scholar
  43. 43.
    Cobb W, Carbonell A, Novitsky Y, Matthews B. Central mesh failure with lightweight mesh: a cautionary note. EHS. Berlin; 2009.Google Scholar
  44. 44.
    Zuvela M, Galun D, Djuric-Stefanovic A, Palibrk I, Petrovic M, Milicevic M. Central rupture and bulging of low-weight polypropylene mesh following recurrent incisional sublay hernioplasty. Hernia. 2014;18(1):135–40. Scholar
  45. 45.
    Petro CC, Nahabet EH, Criss CN, Orenstein SB, von Recum HA, Novitsky YW, et al. Central failures of lightweight monofilament polyester mesh causing hernia recurrence: a cautionary note. Hernia. 2015;19(1):155–9. Scholar
  46. 46.
    Lerdsirisopon S, Frisella MM, Matthews BD, Deeken CR. Biomechanical evaluation of potential damage to hernia repair materials due to fixation with helical titanium tacks. Surg Endosc. 2011;25(12):3890–7. Scholar
  47. 47.
    Klosterhalfen B, Junge K, Hermanns B, Klinge U. Influence of implantation interval on the long-term biocompatibility of surgical mesh. Br J Surg. 2002;89(8):1043–8. Scholar
  48. 48.
    Klosterhalfen B, Klinge U. Retrieval study at 623 human mesh explants made of polypropylene—impact of mesh class and indication for mesh removal on tissue reaction. J Biomed Mater Res B Appl Biomater. 2013;101(8):1393–9. Scholar
  49. 49.
    Cavallo JA, Greco SC, Liu J, Frisella MM, Deeken CR, Matthews BD. Remodeling characteristics and biomechanical properties of a crosslinked versus a non-crosslinked porcine dermis scaffolds in a porcine model of ventral hernia repair. Hernia. 2015;19(2):207–18. Scholar
  50. 50.
    Klinge U, Klosterhalfen B, Muller M, Schumpelick V. Foreign body reaction to meshes used for the repair of abdominal wall hernias. Eur J Surg. 1999;165(7):665–73.CrossRefGoogle Scholar
  51. 51.
    Grabel D, Prescher A, Fitzek S, Keyserlingk DG, Axer H. Anisotropy of human linea alba: a biomechanical study. J Surg Res. 2005;124(1):118–25. Scholar
  52. 52.
    Hollinsky C, Sandberg S. Measurement of the tensile strength of the ventral abdominal wall in comparison with scar tissue. Clin Biomech (Bristol, Avon). 2007;22(1):88–92.CrossRefGoogle Scholar
  53. 53.
    Martins P, Pena E, Jorge RM, Santos A, Santos L, Mascarenhas T, et al. Mechanical characterization and constitutive modelling of the damage process in rectus sheath. J Mech Behav Biomed Mater. 2012;8:111–22. Scholar
  54. 54.
    Ben Abdelounis H, Nicolle S, Ottenio M, Beillas P, Mitton D. Effect of two loading rates on the elasticity of the human anterior rectus sheath. J Mech Behav Biomed Mater. 2013;20:1–5. Scholar
  55. 55.
    Kirilova M. Time-dependent properties of human umbilical fascia. Connect Tissue Res. 2012;53(1):21–8. Scholar
  56. 56.
    Kirilova M, Stoytchev S, Pashkouleva D, Kavardzhikov V. Experimental study of the mechanical properties of human abdominal fascia. Med Eng Phys. 2011;33(1):1–6. Scholar
  57. 57.
    Kirilova M, Stoytchev S, Pashkouleva D, Tsenova V, Hristoskova R. Visco-elastic mechanical properties of human abdominal fascia. J Bodyw Mov Ther. 2009;13(4):336–7. Scholar
  58. 58.
    Levillain A, Orhant M, Turquier F, Hoc T. Contribution of collagen and elastin fibers to the mechanical behavior of an abdominal connective tissue. J Mech Behav Biomed Mater. 2016;61:308–17. Scholar
  59. 59.
    Forstemann T, Trzewik J, Holste J, Batke B, Konerding MA, Wolloscheck T, et al. Forces and deformations of the abdominal wall—a mechanical and geometrical approach to the linea alba. J Biomech. 2011;44(4):600–6. Scholar
  60. 60.
    Cooney GM, Lake SP, Thompson DM, Castile RM, Winter DC, Simms CK. Uniaxial and biaxial tensile stress-stretch response of human linea alba. J Mech Behav Biomed Mater. 2016;63:134–40. Scholar
  61. 61.
    Rath A, Zhang J, Chevrel J. The sheath of the rectus abdominis muscle: an anatomical and biomechanical study. Hernia. 1997;1:139–42.CrossRefGoogle Scholar
  62. 62.
    Konerding MA, Bohn M, Wolloscheck T, Batke B, Holste JL, Wohlert S, et al. Maximum forces acting on the abdominal wall: experimental validation of a theoretical modeling in a human cadaver study. Med Eng Phys. 2011;33(6):789–92. Scholar
  63. 63.
    Podwojewski F, Ottenio M, Beillas P, Guerin G, Turquier F, Mitton D. Mechanical response of human abdominal walls ex vivo: effect of an incisional hernia and a mesh repair. J Mech Behav Biomed Mater. 2014;38:126–33. Scholar
  64. 64.
    Deeken CR, Eliason BJ, Pichert MD, Grant SA, Frisella MM, Matthews BD. Differentiation of biologic scaffold materials through physiomechanical, thermal, and enzymatic degradation techniques. Ann Surg. 2012;255:595–604.CrossRefGoogle Scholar

Copyright information

© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2019

Authors and Affiliations

  1. 1.Covalent Bio, LLCSt. LouisUSA
  2. 2.Department of Mechanical Engineering and Materials ScienceWashington UniversitySt. LouisUSA

Personalised recommendations